Jacob D. Kattan

Milk and soy allergy.

Cows milk allergy (CMA) affects 2% to 3% of young children and presents with a wide range of IgE and non-IgE-mediated clinical syndromes, which have a significant economic and lifestyle effect. It is logical that a review of CMA would be linked to a review of soy allergy because soy formula is often an alternative source of nutrition for infants who do not tolerate cows milk. This review examines the epidemiology, pathogenesis, clinical features, natural history, and diagnosis of cows milk and soy allergy. Cross-reactivity and management of milk allergy are also discussed.

Pharmacological and immunological effects of individual herbs in the Food Allergy Herbal Formula-2 (FAHF-2) on peanut allergy.

It was previously shown that a Chinese herbal formula, Food Allergy Herbal Formula 2 (FAHF‐2) composed of nine herbs, blocked peanut‐induced anaphylaxis in a murine model. The current study was designed to investigate the pharmacological actions of individual herbs comprising FAHF‐2 on peanut‐induced anaphylactic reactions in a murine model of peanut allergy and to determine if all nine herbs are necessary to prevent an anaphylactic reaction, or if a simplified formula containing fewer herbs would be equally effective. Some individual herbs reduced peanut‐induced anaphylactic symptoms but no single herb offered full protection from anaphylactic symptoms equivalent to FAHF‐2. The herbs had highly variable effects on histamine release, as well as peanut‐specific serum IgE and IgG2a levels. The herbs also had variable effects on IL‐4, IL‐5 and IFN‐γ levels. A simplified formula comprising the most efficacious tested individual herbs showed only partial efficacy and was not able to reproduce comparably the effects of FAHF‐2, suggesting that component herbs of FAHF‐2 may work synergistically to produce the curative therapeutic effects produced by the whole formula, which appears to be the best option for future clinical trials. Copyright

Allergen component testing for food allergy: ready for prime time?

Food allergies can cause life-threatening reactions and greatly influence quality of life. Accurate diagnosis of food allergies is important to avoid serious allergic reactions and prevent unnecessary dietary restrictions, but can be difficult. Skin prick testing (SPT) and serum food-specific IgE (sIgE) levels are extremely sensitive testing options, but positive test results to tolerated foods are not uncommon. Allergen component-resolved diagnostics (CRD) have the potential to provide a more accurate assessment in diagnosing food allergies. Recently, a number of studies have demonstrated that CRD may improve the specificity of allergy testing to a variety of foods including peanut, milk, and egg. While it may be a helpful adjunct to current diagnostic testing, CRD is not ready to replace existing methods of allergy testing, as it not as sensitive, is not widely available, and evaluations of component testing for a number of major food allergens are lacking.

The Prevalence and Natural History of Food Allergy.

Numerous studies have demonstrated that the prevalence of food allergy is increasing. Not only are more children being diagnosed with food allergies, but studies suggest that when people outgrow their food allergies, it is taking longer than was previously thought. Studies in recent years have noted factors that may lead to a lower likelihood of developing a food allergy, including the early introduction of common food allergens, having a sufficient vitamin D level, or having a higher maternal intake of peanut early in pregnancy. Given a recent report that sensitization to common food allergens did not increase from the late 1980s/early 1990s to the mid-2000s, further studies will need to examine if the rise in food allergy prevalence is due to a change in the relationship between sensitization and clinical allergy or changes in the recognition and diagnosis of food allergy.

Optimizing the Diagnosis of Food Allergy

Accurately diagnosing a patient with a possible food allergy is important to avoid unnecessary dietary restrictions and prevent life-threatening reactions. Routine testing modalities have limited accuracy, and an oral food challenge is often required to make a definitive diagnosis. Given that they are labor intensive and risk inducing an allergic reaction, several alternative diagnostic modalities have been investigated. Testing for IgE antibodies to particular protein components in foods has shown promise to improve diagnostics and has entered clinical practice. Additional modalities show potential, including epitope binding, T-cell studies, and basophil activation.

Clinical reactivity to soy is best identified by component testing to Gly m 8

Soy allergy affects approximately 0.4% of young children in the USA. A majority of children with soy allergy become tolerant over time, which makes it important that allergists reassess these patients on a regular basis. An accurate assessment of patients with a suspected soy allergy is vital, because avoidance of soy is extremely difficult, it is a common ingredient in processed foods, and consumption of soy-containing food additives (soy isolate, soy concentrate, and soy flour) is increasing in Western diets. Diagnosis of soy allergy is complicated by a high rate of false positives on routine IgE testing, as several studies have identified a dissociation between high levels of specific IgE (sIgE) to soy proteins and low rates of clinical symptoms. Although a soybean sIgE level of 30 kUA/L has been reported to achieve 94% specificity in predicting clinical reactivity, this level carries a sensitivity of only 44%. This study examines the utility of skin prick tests (SPT), soy sIgE, and component testing, for diagnosing allergy to soy. Phadia Immunology Reference Laboratory (PiRL, Portage, Mich) developed commercial IgE testing to the soy components Gly m 4, 5, and 6, and recently developed testing to the component Gly m 8, a 2S albumin. Previous studies on soy components have yielded conflicting results. In 2011, Ito et al reported that Gly m 5 and 6 were associated with severe clinical reactions caused by soybean in Japanese children, and that analysis of IgE antibodies to Gly m 5 and Gly m 6 will most likely better predict soybean allergy than an extract-based test. In 2012, Fukutomi et al reported that, in their Japanese cohort, a high level of IgE to recombinant Gly m 4 was associated with adult soybean allergy. More recently, Ebisawa et al reported that IgE to the 2S albumin Gly m 8 was significantly greater in children reactive to soy than those who were asymptomatic, whereas IgE levels to Gly m 5 and Gly m 6 were not. Klemans et al also reported that Gly m 8 had the best accuracy in diagnosing soy allergy, although the area under the curve (AUC) for this component was comparable to SPT and sIgE to soy extract. Limitations of these previous studies examining soy components include their geographic limitations to Europe and Asia, their utilization of patients diagnosed with soy allergy without confirmation by an oral food challenge (OFC), and their comparison of IgE levels from subjects with soy allergy to negative controls who were known to tolerate soy and have significantly lower soy sIgE levels. Here we analyze IgE results to the components Gly m 4, 5, and 6, as well as the new 2S albumin component, Gly m 8, among children from the USA who underwent OFCs for the evaluation of suspected soy allergy. The study protocol was approved by the Institutional Review Board (IRB) of the Icahn School of Medicine at Mount Sinai. The soy OFCs were performed at the Jaffe Food Allergy Institute, a pediatric, university-based outpatient practice, between December 2006 and September 2013. Patients were referred for an open OFC by our allergists on the basis of their clinical impression. No cutoff age, sIgE value, or SPT wheal size precluded challenge. Typically these patients did not have a history of recent objective allergic symptoms on ingestion of soy, and most demonstrated sensitization to soy with 35 of 40 (87.5%) having a positive SPT (1 did not have this test performed), and 40 of 41 (97.6%) patients having detectable sIgE (>0.35 kUA/L) to soy extract. Charts were reviewed for demographic data, SPT results (extract from Greer, Lenoir, NC), and OFC outcomes. The OFCs were performed per published guidelines, with most challenges using doubling doses every 15 minutes until an age-appropriate serving size was ingested. For subjective symptoms, challenges were temporarily halted, and then continued following resolution of symptoms if the supervising physician deemed it safe to proceed. Treatment decisions were based on the supervising clinician’s judgment. Soy component testing was performed on sera obtained within 1 year of an OFC to soy from patients participating in an IRBapproved study evaluating component testing to a variety of foods or from subjects who had serum banked as part of the Food Allergy Resource Initiative. IgE to soy extract and the components Gly m 4, 5, 6, and 8 were measured with the ImmunoCAP system. Differences between groups were analyzed with the Mann-Whitney U test for nonparametric data; a P value of <.05 was considered significant for all tests. The diagnostic value of each test was assessed with an area under the receiver operating characteristic (ROC) curve (AUC). Demographic data and test results from 41 patients who underwent a soy OFC (median age 7 years, 73% male) are shown in Table E1 (see this article’s Online Repository at www.jaci-inpractice.org). Overall, 18 (44%) of the challenges elicited a reaction. There was no difference between those who tolerated versus reacted to soy in median age or sex, or the

Anaphylaxis management before and after implementation of guidelines in the pediatric emergency department.

Despite availability of published anaphylaxis guidelines, studies demonstrate shortcomings in diagnosis and management, including a lack of epinephrine administration when indicated and failure to provide epinephrine prescriptions and emergency action plans on emergency department (ED) discharge. Use of clinical guidelines in settings such as the ED has been associated with improvement, primarily in adult populations. We sought to evaluate the impact of anaphylaxis guidelines in the ED of a large pediatric hospital.

Safely Diagnosing Clinically Significant Penicillin Allergy Using Only Penicilloyl-Poly-Lysine, Penicillin, and Oral Amoxicillin

E Macy, EW Ngor. J Allergy Clin Immunol: In Practice. 2013;1:258–263 To evaluate if it is adequate to identify clinically significant penicillin allergy by using only the commercially available penicilloyl-poly-lysine and penicillin skin tests followed by an oral amoxicillin challenge. A total of 500 sequential subjects with a history of penicillin allergy evaluated at the Kaiser Permanente Health Care Program were included in this study. A potential case of allergy to penicillin was defined as any penicillin class antibiotic allergy entry in the drug allergy section of the electronic medical record. The mean age of participants …

Auvi-Q Versus EpiPen: Preferences of Adults, Caregivers, and Children

CA Camargo Jr, A Guana, S Wang, FE Simons. J Allergy Clin Immunol : In Practice. 2013;1(3):266–272 To determine the preference for the new epinephrine autoinjector, Auvi-Q, or the EpiPen with regard to method of instruction, preference to carry, device size, and device shape. Subjects were recruited from 12 office-setting research facilities throughout the United States. Participants ( n = 693) were grouped into adults aged 18 to 65 years (241), caregivers who were parents/guardians aged 18 to 65 years of children aged 5 to 17 years (228), and children aged 11 …

The Use of Adrenaline Autoinjectors by Children and Teenagers

L Noimark, J Wales, G Du Toit. Clin Exp Allergy. 2011;42(2):284–292 To evaluate the rate at which adrenaline autoinjectors are used during anaphylactic reactions by patients who have had them prescribed, and to assess the number of devices used for each reaction. Participants ( N = 969) were children and teenagers aged 18 years or less who had been prescribed an adrenaline autoinjector for at least 1 year, recruited from 14 pediatric allergy clinics throughout the United Kingdom. The mean age of participants was 8 years, and approximately half had coexistent asthma. Subjects had been given an allergy management …